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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 11 /5/2018 <br />Name Kyra Clark Department apital& <br />Inclusion <br />BPW Date 11/13/2018 Phone Extension 7500 <br />nm <br />R mire Prior to Submittal to Board <br />... __M .... _.._..._...... _.._ <br />Legal ® Attorney Name Sandra Kennedy <br />Controller ® Controller review is required for all Contracts $5,000.00 or more and <br />greater than one year in length per the City Purchasing Policy <br />Purchasing ❑ <br />ITITmIT®mITmmCheck the <br />Agreement <br />Professional Services <br />Bid Opening <br />Quote Opening <br />El Change Order No. <br />F1 Ease/Encroach. <br />Other: <br />wiate Item Type - eo ►mod for All Submissions <br />Contract E] Proposal <br />Resolution <br />❑ Bid Award ❑ Req. to Advertise <br />0 Quote Award <br />C/O & PCA No. ❑ PCA <br />❑ Traffic Control <br />Required Information <br />Company or Vendor Name ACTIVATE CLINIC <br />Addendum <br />❑ Title Sheet <br />New Vendor ❑ Yes Z No [:] If Yes, Approved by Purchasing <br />MBE/WBE Contractor ❑ MBE WBE <br />MBE/WBE Contractor Requested ® No ❑ Yes Name of Company <br />Project Name EmployeemmClinic Contract Renewal <br />Project Number <br />Funding Source Health Insurance Fund <br />Account No. 711-0401-671-31-06 <br />..._....... _ �._ _..,.6. <br />Amount $27.71 per member per month (PMPM), estimated at 2,900 <br />members for a total estimated cost of $964,308 <br />Terms of Contract The agreement covers the 2019 calendar year, <br />Purpose/Description Anthem administers the Cit 's self -funded healthmminsurance medical <br />and p,rescription program and serves as the Cit 's stop loses carrier. <br />Z Required Contractor's Certification Form Attached (Non <br />Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc.) <br />Rq <br />.waw ,....cared FormmCh�` a Orders OnN" <br />Amount of Increase $ <br />❑�I Decrease $ <br />Previous Amount $ _ <br />Current Percent of Change: % <br />New Amount $..................._. <br />Total Percent of Change: % <br />Dispersal After Approval <br />Copy Original <br />® ❑ Kyra Clark, Ben Dougherty, Tierra Davis <br />El1:1 I'll... .... _........­.........._ ... __ <br />